Splenosis presenting as occult gastrointestinal bleeding.

A 48-year-old man presented with recurrent gastrointestinal bleeding and anemia. Routine endoscopic evaluation was nondiagnostic. Angiography demonstrated multiple apparent arteriovenous malformations. Exploratory laparotomy revealed numerous splenic implants along the small and large bowels, some of which had apparently eroded through the bowel mucosa and bled. Excision of these penetrating lesions prevented further bleeding. An incidentally noted renal cell cancer was also resected. The patient's splenosis was the result of childhood trauma that caused splenic rupture and precipitated splenectomy. Splenosis develops frequently following traumatic splenic rupture. Experimental evidence suggests that the presence of an intact spleen suppresses the growth and development of splenic implants. Following splenectomy, splenules may replace some of the "housekeeping" and immunologic functions of the spleen, but even patients with documented splenosis should be considered functionally hyposplenic. While in most cases splenules cause no symptoms, splenosis must be considered in the differential diagnosis of previously splenectomized patients who present with unexplained masses or occult bleeding.

Inhibition of UVR-induced tanning and immunosuppression by topical applications of vitamins C and E to the skin of hairless (hr/hr) mice.

Exposure of C3HBYB/Wq hairless (hr/hr) mice to ultra-violet radiation (UVR) for 15 days induced intense tanning of their dorsal skin. Small, dark freckles appeared first, gradually enlarging and coalescing as treatment progressed yielding a uniform tan. Histologically, the gross changes in skin color were matched initially by the appearance of scattered epidermal melanocytes that subsequently proliferated to form discrete, progressively expanding and abutting populations resulting in a uniform melanocyte network throughout the basal layer of the interfollicular epidermis. In contrast, when applied topically before each daily exposure to UVR, a cream or lotion vehicle containing both vitamins C and E (Vits C/E) inhibited UVR-induced erythema and tanning. Application of Vits C/E, both before and after irradiation, was no more effective in providing photoprotection than pre-treatment only. At the tissue level, UVR-induced proliferation and melanogenesis of melanocytes were reduced compared with irradiated controls. The density of individual melanocyte populations was reduced, as was the number of melanocyte populations achieving merger (confluence) with others. Confluence grades and cell counts, estimating the maximum density of melanocyte populations in UVR-Vits C/E-treated mice, were approximately two thirds those of UVR-vehicle-treated controls. However, tanning was only one fifth that of UVR-vehicle-treated controls, suggesting that melanogenesis was also inhibited. In addition to its inhibitory actions on irradiated melanocytes, Vits C/E also inhibited UVR-induced suppression of contact hypersensitivity (CHS) in haired (Hr/hr) and hr/hr mice of the C3HBYB/Wq strain. The common denominators for most, if not all, of the influences of topically-applied Vits C/E in muting the responses of the melanocyte and immune systems to UVR may stem from the vitamins' combined ability to suppress UVR-stimulated inflammation and its associated cascade of mediators.

Effects of psychological intervention on panic attack patients in the emergency department.

For patients initially seen in the emergency department (ED) for panic attack, this study evaluated the effect of two brief psychological interventions in the ED on later utilization of emergency, psychiatric, and nonpsychiatric medical department services. Each of the two intervention groups received usual ED care, a brochure on panic disorder, and a referral to treatment at the psychiatry department; one of the two groups also received 20-30 minutes of contact with a representative from the psychiatry department. Both intervention groups were compared with a historical control group. The contact condition reduced ED use after the initial visit to the ED, although all three groups had more visits to the psychiatry department and to all nonpsychiatric departments. This decrease was statistically significant (P = 0.0017) when compared with the brochure condition but not when compared with the historical control group (P = 0.0672). The decrease seen in ED use is an important therapeutic and economic finding.

The impatient therapist: managed care and countertransference.

The conduct of therapy is particularly vulnerable to the influence of impatience. External pressures on the therapist to work quickly intrude on the session. When therapists are unconscious of their own impatience, it is more likely to reduce their ability to listen fully, to understand the extent of the patient's problems, and to participate in the rapidly shifting dance that makes therapy effective. Since the external factors that encourage this impatience are unlikely to abate, therapists need to become more aware of these influences and to consciously develop coping strategies. Impatience can arise from a number of places-the departure from any plan or timetable we have set for therapy, a desire to satisfy third parties, worry that the work is not progressing quickly enough, doubts about our ability to help, fear of "failure," confusion of process with "product," and attachment to favorite treatments. Aversion, attachment, and confusion have been well charted by Buddhist writers as hindrances to clear perception. The solution they propose is to face these obstacles directly, by noting their appearance, development, and passing away. While frequently an unpleasant process, such self-examination maximizes our chances of listening carefully and compassionately to each person who consults us.

Integrating self and system: an empty intersection?

Synthesizing individual and family therapies can founder if the underlying epistemological assumptions concerning "what is self" are not taken into account. Most individual therapies assume self "really" exists as a relatively stable internal entity, the repository of residues of experience where traits, memories, et cetera are organized via internal schemas. Such a view tends to treat self as a thing, and implies that psychological problems are the result of internal deficits or conflicts; this can lead to difficulties in therapy. In contrast, ecosystemic views employ constructivist and contextualist approaches that are more fluid. However, by basing autopoetic self-organization in language, ecosystemic epistemology still separates subject from object. Adopting a perspective in which self has no fixed, distinguishing characteristics can resolve many difficulties and create a dimensionless point where self and system, individual and family, therapist and client can meet without hindrance.

Influence of depigmenting chemical agents on hair and skin color in yellow (pheomelanic) and black (eumelanic) mice.

Topical applications of monobenzylether of hydroquinone (MBEH) or intraperitoneal injections of phenol induced graying of hair in eumelanic mice but had little effect on hair color in pheomelanic mice. Amcinonide, an anti-inflammatory agent, elicited whitening of a few hairs in both pheomelanic and eumelanic mice. In phenol-treated eumelanic mice, damaged follicular melanocytes were uprooted from hair bulbs and incorporated into the developing hair. The fate of follicular melanocytes in MBEH- or amcinonide-treated mice was not determined since hair growth and graying were more variable than in phenol-treated mice. In contrast to the susceptibility of eumelanic hair follicles to depigmentation by phenol or MBEH, the tail skin of eumelanic or pheomelanic mice was not depigmented by these agents. Overall, during the 3 week period of treatment that was sufficient for phenol or MBEH to elicit graying of hair, epidermal melanocytes of the tails of eumelanic or pheomelanic mice either failed to respond (phenol) or were stimulated in their "proliferative" and melanogenic activity (MBEH). In contrast, amcinonide brought about a marked reduction in the numbers of DOPA-positive epidermal melanocytes inhabiting the tails of eumelanic or pheomelanic mice. Amcinonide exerted a deleterious influence on the structure and function of tail epidermis. Its actions were partly reversed by simultaneous treatment with MBEH but not with prostaglandin (PGE2).

Reactivity of microhemagglutination, fluorescent treponemal antibody absorption, and venereal disease research laboratory tests in primary syphilis.

Seroreactivity in 130 cases of primary syphilis was 91.5% by fluorescent treponemal antibody absorption test, 82.3% by microhemagglutination (MHA-TP test), and 68.5% by the Venereal Disease Reseach Laboratory (VDRL) test. The MHA TP test generally became reactive earlier than the VDRL test and confirmed all reactive and most weakly reactive VDRL results.

Comparison of serum and plasma specimens for syphilis serology using the reagin screen test.

One serum and three plasma samples were obtained from each of 125 normal individuals and from 140 patients with treated or untreated syphilis. Serum samples were tested by the Venereal Disease Research Laboratory (VDRL) test and by the Reagin Screen Test (RST). Plasma specimens were tested only with the RST. When tested within 24 h after collection, all specimens from normal individuals were nonreactive. Plasma specimens from normal individuals stored for up to 72 h after collection continued to yield a clearly nonreactive result in 423 of the 426 samples tested by the RST. Serum and plasma samples from syphilis patients tested within 72 h after collection by the RST yielded qualitative and quantitative results almost identical to results of serum tested by the VDRL test.

Primary osteogenic sarcoma of the heart.

The clinical course of a 17-year-old boy with primary osteogenic sarcoma of the left atrium with partial obstruction of the mitral valve and the right pulmonary veins is described. After operative removal of the tumor, echocardiography documented its rapid recurrence. Despite two subsequent open-heart operations and adjuvant chemotherapy and radiotherapy, the patient died twenty-one months after the initial symptoms. Previous reports of such tumors are reviewed, and technical difficulties of removal are discussed.

The desensitization derby: in vivo down the backstretch, imaginal at the wire?

Recontacted 17 Ss who had undergone successful imaginal or in vivo desensitization for snake phobia and had been evaluated pre- and posttreatment for a 9-month follow-up. Main findings were that: (a) overall treatment gains were maintained through the follow-up period; (b) differential gains in favor of the in vivo technique on one behavioral and two self-report snake-specific criteria were dissipated; and (c) imaginal Ss registered a reduction in self-rated fear during an approach task from posttesting to follow-up. Results are discussed in relation to the notion of cognitive rehearsal as a means of self-reinforcing treatment gains.

Rat bite fever misdiagnosed as Rocky Mountain spotted fever.

A patient who had been exposed to ticks and who had also been bitten by a laboratory rat developed fever, headache, and a rash. He was treated with chloramphenicol for Rocky Mountain spotted fever, and recovered. Blood cultures, however, grew Streptobacillus moniliformis, a causative agent of rat bite fever. The case report illustrates the clinical similarities between rat bite fever and Rocky Mountain spotted fever.

Failure of Dacron prostheses caused by structural defect.

Intrinsic prosthetic failure is quite uncommon since the advent of Dacron prostheses. Only 24 cases of arterial prosthetic failure have been described in the literature. Our experience consists of two additional failures of knitted Dacron prostheses. The first patient developed aortojejunal fistula due to a defect of the aortic prosthesis 6 years after resection and replacement of an abdominal aortic aneurysm. The analysis of the graft revealed a defect in the form of a dropped stitch, which caused a weak spot where the prosthesis was able to be torn apart longitudinally. The second patient had femoropopliteal bypass and 6 years later developed degeneration with aneurysmal formation of the entire length of the prosthesis. Optical microscopy of this prosthesis exhibited mostly transverse failures which were coincident with valleys of the corrugated prosthesis. This was indicative of a defect that rendered the corrugation root too weak to withstand normal arterial pressures. This presentation emphasizes the seldom and serious complication of prosthetic failure due to defect of the prosthetic material. Details of scanning electron microscopy of the prosthesis, clinical presentation, angiography, and pathological findings with treatment also are discussed.